Reducing short-acting beta-agonist overprescribing in asthma: lessons from a quality-improvement prescribing project in East London.

BACKGROUND: Excess prescription and use of short-acting beta-agonist (SABA) inhalers is associated with poor asthma control and increased risk of hospital admission. AIM: To quantify the prevalence and identify the predictors of SABA overprescribing. DESIGN AND SETTING: A cross-sectional study using anonymised clinical and prescribing data from the primary care records in three contiguous East London boroughs. METHOD: Primary care medical record data for patients aged 5-80 years, with 'active' asthma were extracted in February 2020. Explanatory variables included demography, asthma management, comorbidities, and prescriptions for asthma medications. RESULTS: In the study population of 30 694 people with asthma, >25% (1995/7980), were prescribed ≥6 SABA inhalers in the previous year. A 10-fold variation between practices (<6% to 60%) was observed in the proportion of patients on ≥6 SABA inhalers/year. By converting both SABAs and inhaled corticosteroids (ICSs) to standard units the accuracy of comparisons was improved across different preparations. In total, >25% of those taking ≥6 SABAs/year were underusing ICSs, this rose to >80% (18 170/22 713), for those prescribed <6 SABAs/year. Prescription modality was a strong predictor of SABA overprescribing, with repeat dispensing strongly linked to SABA overprescribing (odds ratio 6.52, 95% confidence interval = 4.64 to 9.41). Increasing severity of asthma and multimorbidity were also independent predictors of SABA overprescribing. CONCLUSION: In this multi-ethnic population a fifth of practices demonstrate an overprescribing rate of <20% a year. Based on previous data, supporting practices to enable the SABA ≥12 group to reduce to 4-12 a year could potentially save up to 70% of asthma admissions a year within that group.

Response to Comment on "Rapid cooling and cold storage in a silicic magma reservoir recorded in individual crystals".

In a recent paper, we used Li concentration profiles and U-Th ages to constrain the thermal conditions of magma storage. Wilson and co-authors argue that the data instead reflect control of Li behavior by charge balance during partitioning and not by experimentally determined diffusion rates. Their arguments are based on (i) a coupled diffusion mechanism for Li, which has been postulated but has not been documented to occur, and (ii) poorly constrained zircon growth rates combined with the assumption of continuous zircon crystallization.

Rapid cooling and cold storage in a silicic magma reservoir recorded in individual crystals.

Silicic volcanic eruptions pose considerable hazards, yet the processes leading to these eruptions remain poorly known. A missing link is knowledge of the thermal history of magma feeding such eruptions, which largely controls crystallinity and therefore eruptability. We have determined the thermal history of individual zircon crystals from an eruption of the Taupo Volcanic Zone, New Zealand. Results show that although zircons resided in the magmatic system for 103 to 105 years, they experienced temperatures >650° to 750°C for only years to centuries. This implies near-solidus long-term crystal storage, punctuated by rapid heating and cooling. Reconciling these data with existing models of magma storage requires considering multiple small intrusions and multiple spatial scales, and our approach can help to quantify heat input to and output from magma reservoirs.

Paramedic specialization: a strategy for better out-of-hospital care.

Demographic, economic, and political forces are driving significant change in the US health care system. Paramedics are a health profession currently providing advanced emergency care and medical transportation throughout the United States. As the health care system demands more team-based care in nonacute, community, interfacility, and tactical response settings, specialized paramedic practitioners could be a valuable and well-positioned resource to meet these needs. Currently, there is limited support for specialty certifications that demand appropriate education, training, or experience standards before specialized practice by paramedics. A fragmented approach to specialty paramedic practice currently exists across our country in which states, regulators, nonprofit organizations, and other health care professions influence and regulate the practice of paramedicine. Multiple other medical professions, however, have already developed effective systems over the last century that can be easily adapted to the practice of paramedicine. Paramedicine practitioners need to organize a profession-based specialty board to organize and standardize a specialty certification system that can be used on a national level.

Characterisation and expression of the pathway from UDP-glucose to UDP-xylose in differentiating tobacco tissue.

The pathway from UDP-glucose to UDP-xylose has been characterised in differentiating tobacco tissue. A xylogenic suspension cell culture of tobacco has been used as a source for the purification of the enzymes responsible for the oxidation of UDP-glucose to UDP-glucuronic acid and its subsequent decarboxylation to UDP-xylose. Protein purification and transcriptional studies show that two possible candidates can contribute to the first reaction. Most of the enzyme activity in the cultured cells could be accounted for by a protein with an Mr of 43 kDa which had dual specificity for UDP-glucose and ethanol. The cognate cDNA, with similarity to alcohol dehydrogenases (NtADH2) was expressed in E. coli to confirm the dual specificity. A second UDP-glucose dehydrogenase, corresponding to the monospecific form, ubiquitous amongst plants and animals, could not be purified from the tobacco cell cultures. However, two cDNAs were cloned with high similarity to the family of UDP-glucose dehydrogenases. Transcripts of both types of dehydrogenase showed highest expression in tissues undergoing secondary wall synthesis. The UDP-glucuronate decarboxylase was purified as polypeptides of Mr 87 and 40 kDa. Peptide fingerprinting of the latter polypeptide identified it as a form of UDP-glucuronate decarboxylase and functionality was established by expressing the cognate cDNA in E. coli. Expression of 40 kDa polypeptide and its corresponding mRNA was also found to be highest in tissues associated with secondary wall formation.